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Based on observation, interview and record review, the facility failed to implement the facility's policies for daily checks of the Operating Room (OR) crash cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest) and malignant hyperthermia (a condition that triggers a severe reaction to certain drugs used as part of anesthesia for surgery) cart for 31 of 47 days during the time period of 6/1/19 to 7/17/19. This failure had the potential for emergency supplies, medications and equipment to not be available during a patient respiratory or cardiac emergency or malignant hyperthermia reaction, with a potential negative outcome for patients.

Findings:

A review of the facility policy titled "Daily Operational Check of Crash Cart," dated 10/2017, indicated that an operational check (a check to verify the ambu bag (hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was present, the defibrillator (equipment used to control heart fibrillation by application of an electric current to the chest wall or heart) self-test was completed, confirmation the lock was secured and the lock number matched the cart log) of the facility's crash carts was performed daily by a nurse. A log sheet was completed by the nurse performing the daily operational check.

A review of the facility policy titled "Daily Check of the Malignant Hyperthermia Cart," dated 10/17, indicated that a licensed staff member of the Surgical Services Department checked the Malignant Hyperthermia Cart daily to ensure constant readiness. A licensed staff member documented the lock number and daily check on the log.

During an interview, concurrent observation and daily cart check logs review on 7/17/19 at 1:55 pm, with Director of Nurses (DON), the crash cart and malignant hyperthermia carts were observed in the OR. The daily operational check logs for both carts were observed to have multiple blank lines for the time period of 6/1/19 to 7/17/19, indicating the carts had not been checked according to the facility's policies. The daily check logs contained blank lines for the following dates as confirmed by the DON.

Crash Cart Record:
June 6, 7, 8, 9, 12, 13, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30
July 1, 2, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16 and 17

Malignant Hyperthermia Cart Record:
June 6, 7, 8, 9, 12, 13, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30
July 1, 2, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16 and 17

During an interview and concurrent facility policy and record review on 7/17/19 at 2:09 pm, with Assistant Chief Nursing Officer (ACNO) and DON, they confirmed the facility's policies titled "Daily Operational Check of Crash Cart" and "Daily Check of the Malignant Hyperthermia Cart" were not followed or implemented by facility staff for the above listed dates.

A review of the facility's Operating Room Log for the time period of 6/1/19 to 7/17/19, was reviewed and indicated there had been patients present in the OR for scheduled procedures on six of the 31 days when the carts were not checked (June 21, 25 & 28 and July 9, 15 & 17).